The Promise and Problem of Placebo

Placebo is Latin for “I Shall Please” and involves a phenomenon of particular interest to much of Chinese medical research, especially Acupuncture – whose complex clinical physical and emotional interactions largely escape the neat and tidy gold standard for (pharmaceutical) evidencing: the double-blind-randomized-controlled study, and as such deserves special attention.  Many long ago cast and even a few more recent clinical trials have concluded that “Acupuncture is no better than Placebo”- with the “Placebo” group in acupuncture studies receiving various types of “fake” or “sham” acupuncture.  This faking of such a complex interaction, involving presence, deep listening, empathy, talk, touch, and a very specific medical ritual with many healing tools and penetration of the skin is near impossible, and the attempt is usually only on faking the tool ritual bit.   Generally, two types of Placebo needling are used: 1.) needling the “real” acu-points with a “fake” needle: toothpicks, guide tubes (tiny tubes that sterile needles come ensheathed in that we use to insert needles with {blunt, plastic}), stage-sword-needles (that retract into themselves, giving the visual appearance of insertion) and 2.) “Real”/ True needling at “fake” acu-points (a location NOT at an acu-point… off the channel, off point, which researchers theorize should be an inactive PLACE to needle, shouldn’t have clinical effect).  Fake Needles, Real Spots OR Fake Spots, Real Needles…

Let’s be clear: NEVER has there been a “Placebo”/Control/Sham acupuncture group that was truly inactive/inert/a sugar pill- because science has also shown that any noxious stimulation at the skin’s surface if sharp and loud enough, even without penetration of the skin, will fire the a-delta and c nerve fibers, beginning the neural cascade that will have an effect on the brain, a physiological effect – it’s ACTIVE.  And that these nerve fibers – and fascia (a thin connective tissue all over us, at the surface, around the organs – contiguous and continuous and ubiquitous) are everywhere/ all over us, so this neat and tidy notion of discrete lines (channels) and spots (acu-points) being the ONLY places at which a needle would have a physiological impact, is not quite true: also active, if not optimal.  Not to mention the rest of the interaction – the listening, touching, eye contact, empathy, time, and care which epitomize an acupuncture treatment.  In a few studies conventional Western biomedical “usual care” (eg. drugs, orthotics, talk-therapy, physical therapy) were found inferior to our PLACEBO acupuncture groups!  A notable example of this is the huge GERAC (German Acupuncture Trials) study of 2007 where for 1162 low back pain patients, the response rate was 47.6% in the verum {Real/True} acupuncture group, 44.2% in the sham {Placebo/Fake}  acupuncture group, and 27.4% in the conventional therapy group {drugs, PT, exercise}. The studies’ conclusion states:        “Low back pain improved after acupuncture treatment for at least 6 months. Effectiveness of acupuncture, either verum or sham, was almost twice that of conventional therapy.”

Placebo/Sham/Fake groups are ideally, like the sugar pill in drug studies, inactive, inert… However, at best we may conclude these placebo needlings were sub-optimal acupuncture.  In the past 5 years, a few key studies have proven “Verum”/True/Real acupuncture – the active group of a clinical trial – not only to be superior in relieving what-have-you, but also that it more profoundly and precisely affects the brain than Placebo acupuncture.  Real needling and precise needle placement DO matter, DO affect efficacy.

And, after all, Placebo may be the Heart of medicine- and here acupuncture research is beginning to shed Big Light on the fact that any medicine’s (physically acting) tools/ techniques/ pills may actually be a small part of the total effect on the patient, and that it’s the complex human to human interaction  – the ritual –  the rapport, the listening, the empathy, the communication of the desire to help, the touching, the time spent with – which engages the patients’ imagination, faith, belief, and hope – that is the true and deeper Helper.  The complex ritual of an acupuncture clinical encounter is indeed chemically or physiologically influential and this effect seems to come as much from the patients mind, belief & expectations as from physiologic impact of a needle in flesh.

Check out The Program In Placebo Studies & the Therapeutic Encounter –  for much more enlightening information on this important emerging reality in Medicine.

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